beforeCommittee on Energy and CommerceSubcommittee on HealthUnited States House of Representatives

Tuesday September 14, 2010

Mr. Chairman, Members of the Subcommittee, thank you for the opportunity to testify today on behalf of the Secretary for Health and Human Services and the Administrator of the Health Resources and Services Administration (HRSA). I am Dr. Marcia Brand, Deputy Administrator of HRSA. I am pleased to join my other Department colleagues in appearing before you today. In my testimony today, I will provide an overview of HRSA, the programs we deliver and the people we serve. I will also touch upon the relationship between HRSA programs and certain bills under consideration by the Subcommittee. We appreciate your interest in HRSA and welcome the opportunity to work with you, Mr. Chairman, and the Subcommittee.

Introduction

HRSA Overview: The Health Resources and Services Administration helps the most vulnerable Americans receive quality primary health care without regard to their ability to pay. HRSA works to expand the health care of millions of Americans— the uninsured, the underserved and the vulnerable. The individuals served include mothers and their children, those living with HIV/AIDS, and residents of rural areas. HRSA recognizes that people need to have access to primary health care and, through its programs and activities, the Agency seeks to meet these needs. HRSA takes seriously its obligation to diligently and skillfully implement laws that address primary care access. HRSA helps to train future nurses, doctors, and other clinicians, placing them in areas of the country where health resources are scarce. The Agency collaborates with government at the Federal, State, and local levels, and also with community-based organizations, to seek solutions to primary health care problems.

HRSA’s Strategic Plan: HRSA’s mission is to improve health and achieve health equity through access to quality services, a skilled health workforce and innovative programs. The Agency’s strategic plan includes four major goals:

Improve Access to Quality Care and Services

Strengthen the Health Workforce

Build Healthy Communities; and

Improve Health Equity

We at HRSA believe that primary care is more than having a place to go when you are sick. We view primary care as the Institute of Medicine (IOM) does: providing integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of the family and the community.

I will now describe some of the key programs administered by HRSA.

National Health Service Corps

In addition to supporting the provision of direct patient care, HRSA seeks to strengthen primary care by placing health care providers in communities where they are needed most. For example, the National Health Service Corps (NHSC), through scholarship and loan repayment programs, helps Health Professional Shortage Areas (HPSAs) in the U.S. obtain medical, dental, and mental health providers in order to meet the area’s need for health care.

Since its inception in 1970, more than 30,000 primary care physicians, nurse practitioners, certified nurse midwives, physician assistants, dentists, dental hygienists, and mental health professionals have served in the NHSC, expanding access to health services and improving the health of people who live in urban and rural areas where health care is scarce. The NHSC recruitment tools of scholarships and loan repayments enable individuals motivated to provide high quality care for underserved people who in many instances have nowhere else to go for primary care services, to enter and complete health professions training that might otherwise be unaffordable to them, or to relieve them of some of the staggering debt burden they face. The Affordable Care Act will invest $1.5 billion dollars to expand the National Health Service Corps over the next five years.

About half of all NHSC clinicians work in HRSA-supported health centers, which deliver preventive and primary care services to patients regardless of their ability to pay. About 40 percent of health center patients have no health insurance.

Health Professions

In addition to directly assisting in the placement of primary care providers, HRSA supports the health profession programs that provide the infrastructure for their education and training. HRSA’s health professions programs provide policy leadership and grant support for health professions workforce development—making sure the U.S. has the right clinicians, with the right skills, working where they are needed.

HRSA’s health professions programs are designed to address shortages throughout the country. These programs, which include a wide range of training programs, scholarships, loans, and loan repayments for health professions students and practitioners, are essential to producing health professionals who provide high quality, culturally competent health care.

Through the Affordable Care Act, the U.S. Department of Health and Human Services has made a series of new investments worth $250 million to increase the number of health care providers and strengthen the primary care workforce. The investments in the primary care workforce announced in June of this year will be used to boost the supply of primary care providers in this country. The new investments will support the training and development of many new primary care providers over the next five years. Specific activities include:

$168 million in funding to create additional primary care residency slots to train more than 500 new primary care physicians by 2015;

$32 million in funding to support physician assistant training in primary care with the goal of developing more than 600 new physician assistants, who can practice medicine as members of a team with their supervising physician. Physician assistants are trained in a shorter period of time compared to physicians;

$30 million to train an additional 600 nurse practitioners, including providing incentives for part-time students to become full-time and complete their education sooner;

$5 million in funding to encourage States to plan and implement innovative strategies to expand their primary care workforce by 10 to 25 percent over ten years to meet increased demand for primary care services; and

$15 million in funding for the operation of 10 nurse-managed health clinics that both provide comprehensive primary health care services to populations living in medically underserved communities, and assist in the training of nurse practitioners and other health care providers.

Building on the earlier investments made by the American Recovery and Reinvestment Act and the Affordable Care Act, particularly for the National Health Service Corps, these investments will support the training and development of more than 16,000 new primary care providers over the next five years.

Legislation introduced by members of this Subcommittee pertains to a wide range of public health training. One such measure, HR. 1210, the “Arthritis Prevention, Control, and Cure Act of 2009,” which is sponsored by Representative Eshoo, creates a system of loan repayments for pediatric rheumatologists who agree to provide health care in an area where there is a shortage of pediatric rheumatologists. Another measure, H.R. 2999, “The Veterinary Public Health Workforce and Education Act,” sponsored by Representative Baldwin, aims to increase and strengthen the veterinary public health workforce and training capacity in the United States.

HRSA also supports public-private partnerships to encourage health professional training. For example, HRSA funds Area Health Education Centers (AHECs), which are academic and community partnerships that provide health career recruitment programs for high school students and also increase access to health care in medically underserved areas. AHECs address health care workforce issues by exposing students to health care career opportunities that they otherwise would not have encountered, establishing community-based training sites for students in service-learning and clinical capacities, providing continuing education programs for health care professionals, and evaluating the needs of underserved communities.

HRSA health professions programs also identify health professional shortage areas and work to address those shortages. There are programs that reach down into middle schools and high schools to expose promising students to health care careers and others that reach out to experienced clinicians to give them the skills needed to work where health care is scarce. The programs are as diverse as the health workforce.

Maternal and Child Health

HRSA also administers the Title V Maternal and Child Health (MCH) Services Block Grant program, which is the Nation’s oldest Federal-State health care partnership. For 75 years, Title V has provided a foundation for ensuring the health of the Nation’s mothers and children. Title V supported programs provide prenatal health services to more than 2 million women, and primary and preventive health care to more than 17 million children, including almost 1 million children with special health care needs. Today, State MCH agencies, which are located within State health departments, apply for and receive a Title V formula grant each year.

Every $4 of Federal Title V money received must be matched by at least $3 of State and/or local money. This “match” results in there being more than $5 billion annually available for MCH programs at the State and local level. At least 30 percent of Title V Federal funds are earmarked for preventive and primary care services for children and at least 30 percent are earmarked for services for children with special health care needs.

The purpose of the Title V MCH Block Grant is to improve the health of all mothers and children consistent with the applicable health status goals and national objectives, and to provide and assure mothers and children (in particular those with low income or with limited availability of health services) access to quality maternal and child health services.

The Affordable Care Act provided $100 million in FY 2010 for grants to States and tribes to provide evidence-based home visitation services to improve outcomes for children and families who reside in at-risk communities. Through the Maternal, Infant, and Early Childhood Home Visiting Program, nurses, social workers, or other professionals meet with at-risk families in their homes, evaluate the families’ circumstances, and connect families to the kinds of help that can make a real difference in a child’s health, development, and ability to learn—such as health care, developmental services for children, early education, parenting skills, child abuse prevention, and nutrition education or assistance. Home visiting is a strategy that has been used by public health and human services programs to foster child development and address such problems as infant mortality. HRSA and ACF are working collaboratively on this program.

Secretary Sebelius also announced this summer $4.9 million in grants to continue support for 51 Family-to-Family Health Information Centers in each State and the District of Columbia. Created in 2005, the centers are state-wide, family-run organizations that provide information, education, training, outreach, and peer support to families of children and youth with special health care needs and the professionals who serve them. Funding for the centers was extended through 2012 by the Affordable Care Act. The Family-to-Family Health Information Centers are staffed by family leaders with children having special health care needs, and who have expertise in Federal and State public and private health care systems, as well as by health professionals. Overall, these centers help families make more informed health care choices for their children leading to better treatment decisions and improved outcomes.

I would like to recognize a few bills introduced by members of the Subcommittee that support enhanced access and quality of care for our Nation’s mothers and children, and that also have synergies with programs at HRSA. H.R. 3212, which you introduced, Mr. Chairman, aims to improve the health of children and reduce the occurrence of sudden infant death syndrome, an issue that is a high priority at HRSA, and H.R. 1347, Representative Pascrell’s “Concussion Treatment and Cares Tool Act”, which addresses what we call more globally at HRSA traumatic brain injury.

Division of Transplantation

HRSA’s Division of Transplantation provides federal oversight of national systems that support organ, bone marrow, and cord blood donation and allocation systems that ensure these life-saving gifts are given fairly and efficiently to the people who need them most. HRSA’s efforts to increase donation and transplantation mean the difference of life and death for thousands of Americans and their families each year. HRSA’s programs work to not only increase donation, but also improve the health outcomes of those who have transplants.

The Organ Transplantation Program seeks to extend and enhance the lives of individuals with end-stage organ failure for whom an organ transplant is the most appropriate therapeutic treatment. The Program works towards achieving this goal by providing for a national system, the Organ Procurement and Transplantation Network (OPTN), to allocate and distribute donor organs to individuals waiting for an organ transplant. Today, there are 108,000 individuals waiting for an organ transplant. Although a substantial number of transplants were performed in 2009, the demand for organ transplantation continues to far exceed the number of donor organs.

Additionally, each year nearly 18,000 people in the U.S. are diagnosed with life-threatening illnesses where blood stem cell transplantation from a matched donor is their best treatment option. Often, the first choice donor is a sibling, but only 30 percent of people have a fully tissue-matched brother or sister. For the other 70 percent, or approximately 12,600 people, a search for a matched unrelated adult donor or a matched umbilical cord blood unit must be performed.

HRSA funds two major programs that facilitate the provision of blood stem cell units to individuals in need of a transplant. The C.W. Bill Young Cell Transplantation Program supports activities to increase the number of transplants for recipients suitably matched to biologically unrelated donors of bone marrow and cord blood. The National Cord Blood Inventory (NCBI) program supports the collection, processing and storage of a genetically and ethnically diverse inventory of high-quality umbilical cord blood for transplantation. These cord blood units, as well as other units in the inventories of participating cord blood banks, are made available to physicians and patients for blood stem cell transplants through the C.W. Bill Young Cell Transplantation Program.

At any given time, 6,000 people are searching for a matched bone marrow donor or cord blood unit. HRSA acknowledges Representative Matsui’s work on this critical issue through H.R. 6081, the “Stem Cell Therapeutic Research Reauthorization Act” and through H.R. 1230, the “Bone Marrow Failure Disease Research and Treatment Act of 2009.”

ORHP/Telehealth

The Office of Rural Health Policy within HRSA supports programs to increase access to health care for Americans living in rural areas. Recently, the Secretary announced $32 million to support rural health priorities, including funding for telehealth. These activities also dovetail with the President’s Improving Rural Health Care Initiative in the Fiscal Year (FY) 2010 and 2011 budgets, which include a focus on telehealth services.

In many rural communities, patients can only receive certain specialty services locally through the HRSA-funded telehealth program. That is, there are no local providers or traveling clinicians or non-HRSA funded telehealth programs to provide certain specialty services and patients must travel to obtain such services. Telehealth allows patients in underserved and remote areas to receive health care without traveling great distances; it is also frequently used for distance education and health care administration. The services provided via telemedicine range from primary care to highly specialized care found in leading academic medical centers.

Of the $32 million in funds recently announced, more than $2 million was allocated for the Telehealth Network Grant Program, which helps communities build capacity to develop sustainable telehealth programs and networks.

Additionally, more than $1 million was allocated for the Telehealth Resources Center Grant Program, which provides technical assistance to help health care organizations, networks and providers implement cost-effective telehealth programs serving rural and medically underserved areas and populations. The program is designed for entities with a successful track record in helping to develop sustainable telehealth programs.

We understand that Representative Butterfield, a strong supporter of telehealth, intends to introduce a bill to reauthorize certain telehealth programs.

Health Center Program

Health centers are community-based and patient-directed organizations that serve populations with limited access to health care. These include low-income populations, the uninsured, those with limited English proficiency, individuals and families experiencing homelessness, and those living in public housing. These centers are designed to provide accessible, dignified health services to low-income people and their families. Community and consumer participation in the organization and a patient majority governing board were and continue to be the hallmark of the health center model.

Here are some additional points about health centers:

More than half of the nearly 19 million patients seen by health centers in 2009 were members of racial and ethnic minority groups. Nearly forty percent had no health insurance; a third were children.

One out of every 17 people living in the U.S. now relies on a HRSA-funded clinic for primary care.

Community health centers are an integral source of local employment and economic growth in many underserved and low-income communities. In 2009, community health centers across the nation injected more than $11 billion in operating expenditures directly into their local economies.

Community health centers employ more than 9,100 physicians and more than 5,700 nurse practitioners, physician assistants, and certified nurse midwives in a multi-disciplinary clinical workforce designed to treat the whole patient through culturally-competent, accessible, and integrated care.

We appreciate this Subcommittee’s support for the health center program and recognition of the value of health centers as providers of affordable, quality health care.

The Affordable Care Act will invest $11 billion dollars over the next five years for the operation, expansion and construction of health centers throughout the Nation. On August 9th, Secretary Sebelius announced the availability of up to $250 million in grants for health center New Access Points, made available by the Affordable Care Act. These funds will support approximately 350 new service delivery sites in fiscal year 2011. A new access point is a new full-time service delivery site that provides comprehensive primary and preventive health care services. New access points improve the health status and decrease health disparities of the medically underserved populations to be served. Organizations eligible to compete include public or nonprofit private entities, including tribal, faith-based and community-based organizations that meet health center funding requirements.

Health Disparities

Eliminating health disparities is one of HRSA’s top priorities. When it comes to efforts to eliminate disparities in access to care and health outcomes, our largest programs do the heavy lifting: health centers, Ryan White, health professions training, and maternal and child health. The largest portion of the individuals whose health care we support—more than 19 million people—are served through our network of 1,100 health center grantees operating more than 7,900 service delivery sites in every State, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin.

Whether it is clinicians who provide culturally competent care or understanding the unique needs and health concerns of the Lesbian, Gay, Bisexual and Transgender (LGBT) community, HRSA recognizes the importance of these efforts in addressing health disparities. Representative Baldwin’s proposal aimed at LGBT data collection offers a remedy for addressing health disparities impacting the LGBT community.

Another way to address disparities is to improve health outcomes, which is especially important to vulnerable communities, including individuals with chronic illnesses, children and the elderly. HRSA funded six patient navigator projects for a two-year demonstration, beginning in September 2008, to support non-medical health workers, especially in communities with significant health disparities and barriers to health services. The workers, also known as patient navigators, help people learn about chronic disease, such as cancer, diabetes, cardiovascular disease, obesity and asthma, then steer them into screening and treatment as needed. In addition, navigators assist people in finding and using community services that will help them manage chronic disease for longer, healthier lives.

Like patient navigators, medical legal partnerships (MLPs) can help patients improve health outcomes by addressing unmet health-related legal needs. For example, MLPs could be valuable to health centers and their patients who need assistance navigating Federal and State rules and regulations. One study indicated that 90% of health center patients have unmet legal needs.

HRSA has some experience with MLPs, as HRSA's Maternal and Child Health Bureau undertook an initiative in FY2010 to support a small MLP demonstration project. This project provides tools, resources and technical assistance to three Healthy Start Sites to determine if MLP services can positively impact health indicators at these sites.

HRSA believes that the medical-legal partnership (MLP) model could potentially address challenges and issues that affect the health needs of vulnerable populations. And we note that H.R. 5961, Representative Maffei’s and Representative Murphy’s “Medical Legal Partnerships” legislation, aims to address this issue.

HIV/AIDS

As it relates to HIV/AIDS, HRSA’s Ryan White HIV/AIDS Program, which recently entered its twentieth year of providing a legacy of care to persons living with HIV and AIDS, is a critical part of the health care safety net. I would like to acknowledge the essential efforts of this Subcommittee in the Program’s reauthorization. Ryan White provides critical medical care and support services to uninsured, underinsured, and low-income people living with HIV/AIDS who have no other source of care. Through HRSA’s HIV/AIDS Bureau, grants are awarded to cities, States, and local community-based organizations for the purpose of providing primary medical care and support services to individuals living with HIV/AIDS. The program serves over a half million individuals living with HIV/AIDS who rely on us for life-saving, life extending care and treatment.

Additionally, I would like to acknowledge the Administration’s National HIV/AIDS Strategy. The Plan, which is a coordinated national response to the HIV epidemic, aims to accomplish three primary goals: 1) to reduce the number of people who become infected with HIV, 2) to increase access to care and opti­mizing health outcomes for people living with HIV, and 3) to reduce HIV-related health disparities. HRSA will remain involved in the Plan’s implementation.

Conclusion

We are extremely proud of our programs and look forward to continuing to work with you, Mr. Chairman and Members of the Subcommittee, to provide quality primary health care for all.

I appreciate the opportunity to testify today, and I hope this testimony will inform the Subcommittee’s future deliberations on the many important legislative proposals before you. I would be pleased to answer any questions at this time.